Patient Care Protocol Tips
Posted by on 03 August 2015 07:02 PM

Topic: Documenting Patient Care Protocols

Explanation:  This document is aimed at providing tips for correctly documenting which primary patient care protocol was used by the EMS provider during each patient encounter that includes treatment.  When we discuss the element patient care protocol it relates to 9-1-1 types of service and not routine transports.

Topics Covered:

  • Use of “Other”
  • Use of “Not Done”
  • Avoid creating unofficial protocol names
  • Primary protocol used
  • Adult versus pediatric

Use of Other:  At this time EMS providers may select “Other” protocol used.  Other should rarely be used.  Once the use of “Other” as a protocol hits 2% for any individual agency it will be considered non-compliance with quality.  If the use of ”Other” hits 2% statewide “Other” will be removed from the VPHIB system.

Use of Not Done:  At this time EMS providers may select “Not Done” as a protocol used.  “Not Done” should rarely be used when the disposition indicates that a patient existed.  Once the use of “Not Done” as a protocol hits 2% for any individual agency it will be considered non-compliance with quality.  If the use of ”Not Done” hits 2% statewide “Not Done” will be removed from the VPHIB system.

Creating New Protocol Names:  Protocol names will be critical for use in performance measurement.  There will be national and state EMS performance dashboards in the near future and deviating from the established list could falsely measure your agency.  Additional procedures or treatment may fit within an existing protocol name.  Contact VPHIB early in your protocol development for advice on adding additional names.  With such a strong national standard in place it takes time to correctly add items to the standard.

Primary Protocol Used:  The national EMS data standard only allows for selecting a single protocol used during a patient encounter.  While more than one protocol may be used, provider should document the primary protocol used that best describes the patient type/condition that identifies what the providers suspects is their primary impression of the patient.  For example the protocol for a patient in V-Tach with a pulse who has a low blood pressure could be “medical – V-Tach with a Pulse” or “medical – hypotension/shock.”  If V-Tach is the cause of the hypotension “medical – V-Tach with a Pulse” should be selected.

Adult vs Pediatric Protocols:  In version 3 there are two data elements that collect information on what protocol the EMS provider used to treat his/her patient.  eProtocol.01 – Protocol Used and eProtocol.02 – Protocol Age Category.  Agencies and software vendors should not create two separate protocols one for adults and one for pediatrics.  For example Blue Ridge EMS Council has protocols “General – Pain Control (Adult)” and “General – Pain Control (Pediatric).”  When documenting the protocol used for pain management the following should be used:

70 y/o with shingles would be:

  • eProtocols.01/Protocol Used = “General – Pain Control” and;
  • eProtocols.02/Protocol Age Category = “Adult”

and a 12 y/o with sickle cell in crisis would be:

  • eProtocols.01/Protocol Used = “General – Pain Control”
  • eProtocols.02/Protocol Age Category = “Pediatric”

At the state level, VPHIB staffs when creating a report will more like develop the report using eProtocol.01/Protocol Used and the patient’s age (ePatient.15 & 16).  So it is most important to not create additional protocol names. 

As a second example; Lord Fairfax has two protocols one called “Cardiac Arrest (Adult)” and “Cardiac Arrest (Pediatric).  An infant cardiac arrest should be reported as:

  • eProtocols.01/Protocol Used = Cardiac Arrest
  • eProtocols.02/Protocol Age Category = Pediatric

When in doubt and setting up your agency’s v3 system contact VPHIB at:

Call:  804.888.9149

 protocol tips 8-3-15.pdf (98.35 KB)
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